Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

Книга_40_библиотеки_им_акад_М_И_Перельмана

.pdf

Скачиваний:

Добавлен:

15.09.2026

Размер:

13 Мб

Скачать

☆

<<< < Предыдущая 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 3435 / 4135 36 37 38 39 40 41 > Следующая >>>

308

https://t.me/medicina_free

CHAPTER  | MOCKEXAMINATION

38. An 18- year- old woman with a three- month history of abdominal discomfort and unintentional weight loss presented with right- sided abdominal pain and vomiting. Her blood pressure was 110/ 70mmHg and pulse 110 beats per minute.

Investigations:

Haemoglobin 104 g/ L White cell count 13.1 × 109/ L Platelet count 430 × 109/ L Serum C- reactive protein (CRP) 112 mg/ L CT abdomen and pelvis 12- cm length of terminal ileal stricturing with

an adjacent intra- abdominal collection. There are proximal loops of dilated small bowel. Three closely spaced mid- ileal strictures, each about 3cm, are demonstrated proximal to the dilated loops.

What is the most likely surgical procedure?

A. Defunctioning loop ileostomy proximal to the mid- ileal strictures

B. Defunctioning loop ileostomy proximal to the terminal ileal stricture

C. Ileocaecal resection

D. Ileocaecal resection and en bloc mid- ileal stricture resection

E. Ileocaecal resection and three mid- ileal stricturoplasties

Appearances are compatible with active CD.

CHAPTER  | QUESTIONS

https://t.me/medicina_free

309

39. A 54- year- old businessman was referred from the rheumatology clinic with a two- year history of migratory arthralgia of the large joints. He had developed episodic non- bloody diarrhoea and crampy abdominal pain. He had lost weight. On examination, a pericardial rub was audible and there was small volume ascites.

Investigations:

Rheumatoid factor Negative IgA tissue transglutaminase antibody Negative Thyroid stimulating hormone (TSH) Normal Faecal microscopy and culture Negative Faecal ova, cysts, and parasites Negative HIV Negative Gastroscopy Normal Duodenal histology Mild duodenal villous blunting Colonoscopy Normal Colonic histology Normal MR enterography No evidence of small bowel inammation

What is the diagnostic test?

A. Carcinoembryonic antigen

B. Faecal calprotectin

C. HLA- DQ2 and DQ8

D. Periodic acid- Schi (PAS) staining of duodenal biopsies

E. Serology for Treponema pallidum

310

https://t.me/medicina_free

CHAPTER  | MOCKEXAMINATION

40. A 48- year- old woman with primary biliary cholangitis (PBC) attended annual clinic follow- up suering from severe fatigue.

Investigations:

Platelet count 170 × 109/ L Liver stiness measurement (LSM) 10.8 kPa Serum alkaline phosphatase (ALP) 180 U/ L Serum bilirubin 45 µmol/ L Liver ultrasound Coarse irregular heterogenous liver, no focal

lesion, normal portal vein ow, no ascites, spleen size 12cm

Which of the following is true about PBC?

A. Fatigue is an indication for LT

B. Recurrent PBC following LT often leads to graft loss

C. Severity of symptoms does not correlate with stage of disease

D. This patient should undergo endoscopy for variceal screening

E. Women are at increased risk of hepatocellular carcinoma compared with men

41. A 40- year- old woman was reviewed on the ward 24 hours after LT for alcohol- related cirrhosis. The organ donor was positive and the recipient was negative for cytomegalovirus (CMV) (D+/ R−).

What is the most appropriate management regarding CMV infection post- transplantation?

A. Foscarnet prophylaxis for three months

B. Intravenous ganciclovir for two weeks

C. No prophylaxis and send CMV polymerase chain reaction (PCR) only if clinical suspicion

of CMV disease

D. Valganciclovir prophylaxis for three months

E. Weekly CMV PCR during hospitalization and start valganciclovir if persisting viraemia

CHAPTER  | QUESTIONS

https://t.me/medicina_free

311

42. A 43- year- old female was admitted from the mental health unit having reportedly swallowed a foreign object. She denied any symptoms but refused to say what she had ingested.

Which of the following objects may be safely considered for conservative management?

A. 15mm button battery

B. 15mm magnet

C. 15mm × 60mm nail le

D. 20mm coin

E. 25mm metal toothpick

43. A 34- year- old man with complex ileocolonic CD developed a secondary loss of response to iniximab. He had evidence of active disease at recent ileocolonoscopy. His background included psoriasis for which he was under the dermatologists.

Which novel therapy is most appropriate to introduce?

A. Amiselimod

B. Mongersen

C. Tofacitinib

D. Ustekinumab

E. Vedolizumab

44. A 26- year- old- woman attended the IBD clinic. She had left- sided UC diagnosed ve years ago, which was conrmed as quiescent on colonoscopy six months earlier. Despite mesalazine 1.2 g twice daily with good compliance, the patient’s bowel frequency had increased to ve times per day with some rectal bleeding. Her GP had increased the mesalazine to 2.4 g twice daily one week before, but without benet. She was apyrexial and her pulse was 56 beats per minute.

Investigations:

Haemoglobin 134 g/ L White cell count 9.0 × 109/ L Platelet count 320 × 109/ L Serum C- reactive protein (CRP) 40 mg/ L Serum alanine transferase (ALT) 26 U/ L Serum alkaline phosphatase (ALP) 96 U/ L

What should you recommend?

A. Azathioprine

B. Corticosteroid enema

C. Mesalazine enema

D. Mesalazine suppository

E. Oral prednisolone reducing course

312

https://t.me/medicina_free

CHAPTER  | MOCKEXAMINATION

45. A 50- year- old man with alcohol- related cirrhosis and diuretic- controlled ascites was reviewed in clinic. He complained of several months of worsening shortness of breath that improved when he was lying at. He had no other past medical history and was a lifelong non- smoker.

Investigations:

Chest radiograph Normal Oxygen saturations on air 89% Arterial pH on air 7.35 Arterial pO Arterial pCO

7.3 kPa

4.6 kPa

Arterial base excess 5.1mmol/ L

What would be the next best investigation?

Arterial HCO

28.5mmol/ L

A. Lung perfusion scan

B. Spirometry

C. Right- heart catheterization study

D. Transthoracic contrast enhanced echocardiogram

E. Transthoracic echocardiogram

46. A 57- year- old man with extensive UC (pancolitis) was admitted to hospital with bloody diarrhoea (15 times per day). On day three of intravenous hydrocortisone, his stool chart showed nine bloody stools in the last 24 hours, his temperature was 37.6°C, and he denied abdominal pain. Abdominal plain lm excluded toxic megacolon. His blood pressure was 205/ 106mmHg and pulse was 86 beats per minute. His background included treated pulmonary tuberculosis, hypertension, and NAFLD.

Investigations:

Haemoglobin 98 g/ L White cell count 12.0 × 109/ L Platelet count 455 × 109/ L Serum C- reactive protein (CRP) 40 mg/ L Serum cholesterol 3.2mmol/ L Serum magnesium 0.8mmol/ L Serum alanine transferase (ALT) 35 U/ L Serum alkaline phosphatase (ALP) 104 U/ L

What is the most appropriate plan?

A. Continue intravenous steroids for a further 3days

B. Iniximab 5 mg/ kg intravenous induction regime

C. Intravenous ciclosporin at a dose of 4 mg/ kg per day

D. Oral ciclosporin at a dose of 2 mg/ kg per day in divided doses

E. Subtotal colectomy

CHAPTER  | QUESTIONS

https://t.me/medicina_free

313

47. A 68- year- old man was admitted with a one- day history of melaena. He had no relevant past medical history and took no regular medications.

What percentage of patients who are admitted with apparent acute upper GI bleeding do not reveal a cause at initial gastroscopy?

A. 2%

B. 9%

C. 17%

D. 28%

E. 44%

48. Which of the following is a major risk factor for the formation of brown pigment gallstones?

A. Cholangitis

B. Chronic haemolysis

C. Crohn’s disease

D. Pregnancy

E. Rapid weight loss

49. A 64- year- old man presented with large volume melaena. He had a past medical history of type 2 diabetes, peripheral vascular disease with left above- knee amputation, previous endovascular repair of an abdominal aortic aneurysm, and chronic obstructive pulmonary disease. He was a smoker and drank alcohol to excess. On examination, he appeared pale and clammy, pulse 136 beats per minute and blood pressure 86/ 54mmHg.

Investigations:

Haemoglobin 63 g/ L Serum urea 23.5mmol/ L (baseline for patient=11.3) Serum creatinine 124 μmol/ L (baseline for patient=108)

After initial resuscitation, what is the most important rst investigation?

A. Colonoscopy

B. CT angiography

C. Gastroscopy

D. MR angiography

E. Video capsule endoscopy

314

https://t.me/medicina_free

CHAPTER  | MOCKEXAMINATION

50. A 43- year- old man from Argentina was visiting family in the UK. He presented to the emergency department with a ve- month history of abdominal discomfort, anorexia, cough, and shortness of breath.

Investigations:

Haemoglobin 134 g/ L White cell count 8.7 × 109/ L Neutrophil count 5.1 × 109/ L Lymphocyte count 2.9 × 109/ L Monocyte count 0.3 × 109/ L Eosinophil count 0.6 × 109/ L Basophil count <0.1 × 109/ L Platelet count 453 × 109/ L Serum bilirubin 47 µmol/ L Serum alanine transferase (ALT) 23 U/ L Serum alkaline phosphatase (ALP) 180 U/ L CT abdomen (Fig. 11.5)

Fig.11.5 CT abdomen

Reproduced with kind permission from Dr Paul Burn, Consultant Radiologist

What is the most likely diagnosis?

A. Amoebic liver abscess

B. Caroli’s syndrome

C. Hepatocellular carcinoma

D. Hydatid disease

E. Polycystic liver disease

https://t.me/medicina_free

chapter

MOCKEXAMINATION



ANSWERS

1. D. Nodular regenerative hyperplasia (NRH)

• Thiopurines can cause a transient transaminitis, cholestatic hepatitis, sinusoidal obstruction syndrome, and NRH

• NRH occurs in ~1% of IBD patients treated with azathioprine for 10years and is characterized by diuse liver nodularity without annular brosis leading to non- cirrhotic portal hypertension

Four patterns of hepatotoxicity are recognized with the use of thiopurines (azathioprine, 6mercaptopurine, thioguanine):

1. Atransient and usually asymptomatic elevation in serum transaminases is the most common,

occurring in ~10% of patients. It is usually self- limiting, resolves rapidly on drug discontinuation or dose reduction, and is associated with higher levels of the thiopurine metabolite methyl- mercaptopurine.

2. One in 1,000 develop idiosyncratic cholestatic hepatitis with intrahepatic cholestasis on

histology but with only modest elevations in aminotransferases and alkaline phosphatase alongside moderate- to- severe jaundice.

3. Sinusoidal obstruction syndrome (formerly ‘veno- occlusive disease’) is best recognized with

the use of chemotherapy agents or after hematopoietic stem cell transplantation but is rarely reported with chronic thiopurine use. It is characterized by damage to small hepatic vessels causing abdominal pain, jaundice, oedema, and portal hypertension.

4. NRH is a rare liver condition dened by alternating atrophic and hyperplastic areas of liver

parenchyma causing diuse nodulation without annular brosis that can progress to noncirrhotic portal hypertension. The cumulative risk of NRH in patients with IBD treated with azathioprine is 0.5% at 5years and 1.25% at 10years. In patients on long- term azathioprine for AIH who develop features of portal hypertension, both NRH as well as brosis progression must be considered as an underlying cause.

Drug- induced AIH is associated with minocycline, nitrofurantoin, diclofenac, indomethacin, and iniximab. Hepatic brosis can be caused by amiodarone and methotrexate. Steatosis is seen with methotrexate, 5- uorouracil, corticosteroids, and tamoxifen. Granulomatous hepatitis is associated with allopurinol, carbamazepine, methyldopa, phenytoin, and quinidine.

LiverTox. Clinical and research information on drug- induced liver injury [Internet]. Bethesda (MD):National Institute of Diabetes and Digestive and Kidney Diseases; 202– . Azathioprine. [Updated 2 August207]. Available at:https:// www.ncbi.nlm.nih.gov/ books/ NBK548332

Best of Five MCQs for the European Specialty Examination in Gastroenterology and Hepatology. Thomas Marjot, Colleen G C McGregor, Tim Ambrose, Aminda N De Silva, Jeremy Cobbold, and Simon Travis, Oxford University Press (2021). © Oxford University Press. DOI: 10.1093/oso/9780198834373.003.0011

316

https://t.me/medicina_free

CHAPTER  | MOCKEXAMINATION

2. C. Restrict hypotonic uid intake to less than 500 ml per day and commence a mix of 20 g glucose, 3.5 g salt, and 2.5 g sodium bicarbonate in 1 litre water

• Oral glucose- electrolyte mixes (e.g. St Mark’s solution or double strength Dioralyte™) require a sodium concentration greater than 90mmol/ L to achieve net absorption in the jejunum

• Patients with more than 100cm jejunum do not usually require parenteral support

The residual small bowel length following resection, together with the presence or absence of colon in continuity, can help predict what hydration and nutritional support patients will require. Radiological estimation (using magnetic resonance (MR)/ computed tomography (CT) enterography or barium studies) approximates to bowel length but referral to the operation note is important. Patients with more than 100cm jejunum, or 50cm jejunum anastomosed to colon, do not usually require parenteral support.

To achieve net absorption of sodium and water, jejunal contents require a sodium concentration greater than 90mmol/ L. These patients must not be encouraged to drink hypotonic uids ad libitum to quench thirst because this increases stomal losses and worsens hydration. Hypotonic uids (e.g. water, tea, coee, fruit juices) should be restricted to less than 500 mL per day. An oral glucose- electrolyte mix, with a sodium concentration greater than 90mmol/ L, aids water/ sodium balance. St Mark’s solution (20 g glucose, 3.5 g salt, and 2.5 g sodium bicarbonate in 1 litre water) or double strength Dioralyte™ (10 sachets in 1 litre water) are two mechanisms to achieve this. The latter provides a substantial potassium load as well, and should be exercised with caution in patients with a propensity for potassium overload (e.g. renal failure).

Nightingale J, Woodward JM. Guidelines for management of patients with a short bowel. Gut. 2006;55(Suppl 4):iv– 2.

3. E. Underlying primary sclerosing cholangitis (PSC)

• MRCP and CT are used in the diagnosis and staging of perihilar cholangiocarcinoma (pCCA) to characterize degree of biliary and vascular involvement, respectively

• LT is preferable to resection for pCCA in patients with PSC

• Locoregional lymphadenopathy is not a contraindication to resection but is associated with a poorer outcome

pCCA describes tumours located between the secondary branches of the right and left hepatic ducts, and the common hepatic duct proximal to the cystic duct origin. Tumours more proximal to this are called ‘intrahepatic cholangiocarcinomas’ and those involving the common bile duct, up to but not including the ampulla, are called ‘distal cholangiocarcinomas’. Acombination of MRCP and CT is used in the diagnosis and staging of pCCA to characterize degree of biliary and vascular involvement respectively. ERCP also enables detection of strictures and can acquire biliary brushing samples for cytological assessment. Endoscopic ultrasound is associated with high tumour detection but ne needle aspiration should be avoided due to the risk of peritoneal tumour seeding in >80%.

Surgical resection is potentially curative for patients with pCCA without the following exclusion criteria:i) bilateral involvement of the second- order bile ducts; ii) bilateral or contralateral vascular involvement; iii) presence of metastatic disease; iv) underlying PSC. Patients with PSC should preferentially be treated with LT because of the eld defect in PSC and frequent underlying advanced brosis. The presence of locoregional lymphadenopathy is not a contraindication but is associated with a poorer post- surgical outcome. Abutment (as opposed to involvement) of the vasculature is not a contraindication for resection. Surgery for pCCA involves lobectomy with bile- duct resection, regional lymphadenectomy, and Roux- en- Y hepaticojejunostomy. To maximize post- operative liver function, the ipsilateral portal vein is often embolized pre- operatively to

CHAPTER  | ANSWERS

https://t.me/medicina_free

promote contralateral lobe hypertrophy. LT following neoadjuvant chemoradiatherapy oers the best outcomes for patients with unresectable pCCA but only a minority of patients with early stage disease are candidates.

Rizvi S, Khan SA, Hallemeier CL etal. Cholangiocarcinoma— evolving concepts and therapeutic strategies. Nat Rev Clin Oncol. 208;5(2):95– . Doi:0.038/ nrclinonc.207.57.

317

4. D. Dysmotility associated with hypermobile- type Ehlers- Danlos syndrome (hEDS)

• hEDS is associated with functional GI disorders and autonomic dysfunction

• These patients often develop more chronic pain and somatization

• hEDS does not have a known genetic basis at present

Approximately one third of patients presenting to gastroenterology clinics have evidence of joint hypermobility. The Beighton score can be used to formalize the degree of hypermobility, with a positive score dened as >6 in prepubertal children, >5 in postpubertal people, and >4 in those over 50years of age. Patients with both hypermobility and GI symptoms often have evidence of postural orthostatic tachycardia syndrome (POTS) or other autonomic symptoms such as irritable bladder.

hEDS is a clinical diagnosis and there is no known genetic association at present. The 2017 international diagnostic criteria include aspects such as generalized joint hypermobility, positive family history of hEDS, chronic pain, and musculoskeletal pain. The mechanism of GI and autonomic involvement is poorly understood.

Cannabis is known to cause GI upset, including constipation, but usually only when used to excess. The patient is not diabetic and there is no suggestion of an eating disorder causing her symptoms. Mitochondrial disease is unlikely, particularly because there are no visual symptoms.

Fikree A, Chelimsky G, Collins H etal. Gastrointestinal involvement in the Ehlers- Danlos syndromes. Am J Med Genet C Semin Med Genet. 207;75():8– 87. Doi:0.002/ ajmg.c.3546.

5. C. Interstitial cells of Cajal

• Cholecystokinin (CCK) and gastric inhibitory polypeptide (GIP) are gut hormones involved in delaying gastric emptying

• Slow wave stomach contractions are controlled by cells of Cajal whereas phasic contractions of the distal stomach are controlled by the migrating motor complex

The proximal stomach serves as a reservoir for food and, at its maximum relaxation, gastric barostat studies have shown that it can allow over 1L of nutrients to be ingested. In addition, the proximal stomach also helps to regulate the gastroduodenal ow rate and provides the space and time for pepsin and hydrochloric acid to initiate digestion.

The duration of post- prandial motor activity varies according to the volume ingested as well as the chemical characteristics of the ingested foods. The maximum duration of post- prandial motor activity is 120 minutes.

CCK and GIP are hormones involved in producing a negative feedback to slow gastric emptying. CCK regulates gastric emptying and bowel motility to induce satiety, thus delaying gastric emptying. GIP is thought to inhibit gastric acid secretion and reduce the rate at which food is transferred through the stomach, thereby delaying gastric emptying.

Goyal RK, Guo Y, Mashimo H.Advances in the physiology of gastric emptying. Neurogastroenterol Motil. 209 Apr;3(4):e3546. Doi:0./ nmo.3546.

<<< < Предыдущая 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 3435 / 4135 36 37 38 39 40 41 > Следующая >>>

Соседние файлы в папке Библиотека им академика М.И. Перельмана

#
10.10.20267 Мб0Книга_3932_Библиотеки_им_академика_М_И_Перельмана.pdf
#
10.10.20267 Мб0Книга_3934_Библиотеки_им_академика_М_И_Перельмана.pdf
#
10.10.20267 Мб0Книга_3936_Библиотеки_им_академика_М_И_Перельмана.pdf
#
10.10.20267 Мб0Книга_3937_Библиотеки_им_академика_М_И_Перельмана.pdf
#
10.10.20267 Мб0Книга_3938_Библиотеки_им_академика_М_И_Перельмана.pdf
#
15.09.202613 Мб0Книга_40_библиотеки_им_акад_М_И_Перельмана.pdf
#
15.09.202612 Мб0Книга_41_библиотеки_им_акад_М_И_Перельмана.pdf
#
29.08.2026101 Мб0Книга_4366_Библиотеки_им_академика_М_И_Перельмана.pdf
#
29.08.202698 Мб0Книга_4368_Библиотеки_им_академика_М_И_Перельмана.pdf
#
29.08.202694 Мб0Книга_4372_Библиотеки_им_академика_М_И_Перельмана.pdf
#
29.08.202693 Мб0Книга_4373_Библиотеки_им_академика_М_И_Перельмана.epub